Steroids in treatment of temporal arteritis

Sudden loss of vision is an ophthalmological emergency and requires immediate referral to the eye emergency department.

• giant cell arteritis is treated with 40-60 mg per day of prednisolone in the absence of ocular symptoms. In addition, 75 mg aspirin (if no contra-indications) and a proton pump inhibitor should be started (1,2).
  • urgent specialist referral advised – a biopsy of temporal artery should be done ideally within 2 weeks of starting steroid therapy (2).
• if visual symptoms then treatment is with 1mg per kg per day prednisolone (60-80mg) (1). Intravenous methylprednisolone is sometimes used in cases of impending vision loss
  • aggressive treatment of these patients is to prevent vision loss in the contralateral eye, which has 20-50 per cent chance of becoming affected within a short period of time
  • same-day ophthalmologist referral recommended (2)
• steroid treatment is gradually tapered by 5-10mg every two weeks until reaching 20mg per day and then more slowly
  • the effectiveness of treatment is monitored by the patient's ESR. Treatment should not need to be continued for more than a year

Whilst on steroid treatment then other issues such as osteoporosis prevention in the form of calcium supplements and bisphosphonates needs to be considered. Also regular monitoring of blood pressure and blood sugar is essential. The clinical team must maintain a high index of suspicion for infections during courses of high-dose steroid treatment as this may mask symptoms and signs of infection.

Notes:

• there is evidence that adjunctive treatment with methotrexate lowers the risk of relapse and reduces exposure to corticosteroids (3)

Reference:

• (1) Prescriber (2004); 15(10):35-40.
• (2) Clinical Knowledge Summaries (May 2009).Giant cell arteritis
• (2) Mahr AD et al. Adjunctive methotrexate for treatment of giant cell arteritis: an individual patient data meta-analysis.Arthritis Rheum. 2007 Aug;56(8):2789-97.